Rethinking the baby aspirin in the time of COVID

Updated: May 2, 2020

by Al Lewis

Note: this is the "long version," of the post, intended for you and other professionals. FoQs (Friends of Quizzify) can request the short version, designed to be shared with your employees.


The recommendation to take a daily baby aspirin (81 milligrams) as a blood thinner to prevent a heart attack or stroke has a long history. At one point, decades ago, it was totally a thing. At least until it wasn’t, when wiser minds than ours realized:

1. for lower-risk people, thinning the blood increased the likelihood and risk of bleeds more than the benefit of event avoidance; and

2. a little five-cent pill based on a 19th-century technology was not going to eliminate the #1 cause of death in America. (The cartoon below was published during the peak euphoria, needless to say.)

Fortunately, there is now an arbiter to prevent or at least dampen excessive enthusiasm and equally excessive backlashes, by painstakingly reviewing all the evidence in these situations: US Preventive Services Task Force (USPSTF). They are the official arbiter of all things preventive, and their recommendations are law when it comes to Medicare and the Affordable Care Act. (Recommended preventive interventions are costless to the patient.)

They offer five grades for preventive interventions, the first two being the costless ones:

In this case, USPSTF has cut the baby aspirin in half, so to speak, by bestowing a “B” only for adults 50 to 59 who believe (or whose doctors believe) they have a decent chance of a stroke or heart attack in the next ten years. Younger people get an “I” and people in their 60s get a “C” -- specifically because the risk of bleeding might exceed the benefit of avoided stroke and heart attack risk.

That was then. This is now.

We aren’t doctors. So we generally don’t make recommendations, other than our prescient ones last month to lay off the hydroxychloroquine and not to spray Lysol on living things. However, we aren’t shy about recommendations for employees to discuss with their doctor, and baby aspirin is now one of them, for four reasons.

Basis for re-evaluating baby aspirin

First, a heart attack or a stroke may be more debilitating now than historically. That’s because your employees will be less likely to race to the ER at the first signs of a heart attack or stroke, fearing that an ER could be a petri dish of COVID. Elapsed time is a huge factor in these events, so delay could mean the difference between going home in a few days, or not going home at all. This is not just a theoretical concern – the death rate for non-COVID causes has jumped.

Second, due to COVID concerns or stay-at-home advisories, many people are avoiding routine follow-up appointments to monitor their chronic conditions. This means that they might be unaware of changes in health status that create or increase cardiovascular risk. Might that include now needing baby aspirin?

Third, strokes seem more prevalent and severe in people exposed to COVID. For all we know, the particular type of stroke seen in COVID-exposed patients (including blood clots in veins instead of the usual arteries, clots of a type many doctors have never seen before) may not be prevented by a daily baby aspirin. And the absolute risk of stroke among younger people, though increasing in relative terms, is still very low. (The distinction between absolute and relative risk is described here.)

Fourth, this prevalence creates a new risk category not considered by USPSTF -- people who think they might have been exposed to COVID, or have tested positive, or have actually had it. It’s only a guess that aspirin would help here, of course, but that brings us to the other side of the equation, which is risk.

The risk of taking aspirin is bleeding…but opportunities to bleed are way down. For most commercially insured people (excepting those with a history of bleeds), the main risk of excessive bleeding is trauma, like on TV, where actors dressed as EMTs rush a patient into the ER shouting: “He’s a bleeder!” Fortunately, car accidents are way down, presumably along with work-related and sports accidents. Barfights can be pretty bloodless too, if the perps are required to stand six feet apart.

Nonetheless, non-traumatic bleeding remains a risk, so you should be wary of (for example) blood in your stool, either what you can see, or else the stools are blackish. (Rarely, bleeding can also take place within your head, which can be as serious as a stroke. That's why the risks and benefits are balanced so that, as noted below, only some people should be recommended for this. The point of this blog is that "some people" is now a greater "some people" than two months ago,)

So what advice should employees get?

They should send this column to their doctor, along with this summary of the USPSTF recommendation. While COVID always creates unknowns, it is clear that bleeding risk is down (though still present), and stroke severity and prevalence are up. So the harms-benefits analysis shifts, at least for now, quite a bit in favor of daily baby aspirins.

Meanwhile, if we were running USPSTF, we would provisionally nudge the “B” to an “A” for the 50-to-59-year-olds, and institute a provisional “B” for the 60-to-69s and the 40-to-49s with no history of bleeding – as well as for people who think they were exposed to COVID.

And we here at Quizzify will be following our own advice even though we hate taking pills, and used to have trouble swallowing them – until someone suggested coating them in olive oil, a hack that works so well we’ve made a quiz question out of it.

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